Recent successes in surgical procedures such as laparoscopic cholecystectomy have led to the adaptation of other routine surgical procedures to a laparoscopic approach. Thus, for example, procedures such as hernia repair, appendectomy, and most recently, vagotomy, etc., have been successfully performed under laparoscopic guidance.
It is estimated that about twenty million people in the United States suffer from peptic ulcer disease. The overwhelming majority of these patients are adequately managed with conventional medical treatment. Nonetheless, 5-10% of patients with peptic ulcer disease very likely will suffer from failed medical treatment or related complications such as bleeding and perforations. For this group of patients a vagotomy with or without gastric section has proved to be a safe and effective form of treatment.
Many patients, however, are reluctant to undergo major abdominal surgery, at least in part due to the typical subsequent prolonged hospitalization, recovery periods, post-operative discomfort, and cosmetic considerations.
It is considered that laparoscopic highly selective vagotomy may offer many sufferers a safe, feasible and effective alternative to conventional ulcer surgery. It offers many of the advantages associated with a traditional highly selective vagotomy and avoids many of the known disadvantages of a laparotomy. The procedure provides a treatment of peptic ulcer disease, with a relatively short hospital stay, involves minimal post-operative discomfort and allows the patient an early return to work. It is therefore a viable alternative to lifelong medical therapy or an open abdominal operation.
The current indications of laparoscopic vagotomy are limited to the treatment of intractable disease and acute perforation. Operations for both of these conditions have been successfully completed in the United States and Europe. With further experience and refinement of surgical technique, perhaps other conditions such as perforation, bleeding and obstruction may also indicate a role for laparoscopic vagotomy.
The pre-operative evaluation for laparoscopic vagotomy is very similar to that for conventional ulcer surgery. Before surgery, the patient undergoes gastro-intestinal endoscopy as well as contrast studies to determine the extent and severity of the disease. In addition, to evaluate the effectiveness of this new procedure all patients ideally should undergo pre- and post-operative gastric acid studies.
Due to the disadvantages of a bilateral truncal vagotomy and because a conventional highly selective vagotomy may be very difficult to perform under laparoscopic guidance, several modifications of standard ulcer operations are needed. At the University of Maryland, doctors have developed a modified, highly selective vagotomy which can be performed under laparoscopic guidance. One successful technique consists of a posterior truncal vagotomy combined with an anterior highly selective vagotomy performed in a standard fashion by individual ligation of the neurovascular bundles along the lesser curve of the stomach. The procedure is performed under general anesthesia.
The operation is begun with a 1.5 centimeter incision made at the umbilicus. The subcutaneous tissue is gently separated down to the level of the facia. A Veress insufflation needle is introduced into the abdominal cavity. Confirmation of appropriate positioning of the needle is made using standard techniques and carbon dioxide is instilled via an automatic insufflator until a pressure of 12 mm. of mercury is achieved. Accumulation of a appropriate level of pneumoperitoneum is confirmed by monitoring of the intra-abdominal pressure.
The laparoscope with the attached video camera is then inserted into the abdominal cavity. A thorough diagnostic laparoscopy is performed with inspection of the liver, gallbladder, small and large intestine, pelvic structures, and finally, the stomach. The stomach may be moderately distended following the induction of anesthesia. It is considered important to achieve adequate decompression of the stomach prior to beginning the operative dissection.
Accessory trocars may be inserted into the abdominal cavity under direct laparoscopic guidance to minimize the risk of injury to the abdominal viscera. Ports to receive trocars may also be placed either in the left mid-abdomen or just below the xiphoid process on the left.
The operation continues with insertion of a liver retractor which is opened and placed under the left lobe of the liver. This retraction provides excellent exposure of the gastro-esophageal junction, a critical maneuver in the performance of a laparoscopic vagotomy. The retractor, once properly positioned, is secured in place.
The region of the gastro-esophageal junction is then closely inspected.
The esophagus and diaphragmatic crus is mobilized to expose the posterior vagus trunk. The posterior vagal trunk can be ligated with surgical clips, after which a segment of nerve can be excised and sent for further histologic confirmation. Occasionally, a small accessory vagal branch may be identified along the lateral aspect of the esophagus. It is dissected free, ligated and divided.
The next step is to identify the anterior vagus nerve at the gastro-esophageal junction. The course of the anterior nerve along the lesser curve of the stomach is visualized. Each neurovascular bundle is identified and carefully dissected free from the underlying gastric wall, ligated with surgical clips and then transected. Following completion of the anterior highly selective vagotomy, the operative field is irrigated with normal saline. The previously placed clips are inspected to ensure adequate hemostasis.
Following completion of the laparoscopic vagotomy, the laparoscope and surgical trocars are removed from the abdominal cavity. The facial incisions are all closed with a single interrupted absorbable sutures. The skin is reapproximated with surgical clips and sterile dressings are applied.
An alternative to a posterior truncal vagotomy and an anterior highly selective vagotomy is the performance of a bilateral truncal vagotomy. This may be performed either as a planned procedure or following inadvertent injury to the anterior trunk during operative dissection. In such cases, it is necessary to perform drainage of the stomach. Such drainage may be accomplished by either direct pyoplasty, endoscopic balloon dilation or a pyloromyotomy.
Initial results with these relatively new procedures have been encouraging. It appears that a modified laparoscopic highly selective vagotomy may offer a viable alternative to conventional ulcer surgery. Certainly, an operative procedure associated with a one to two-day hospitalization period and a low operative morbidity, may become a valuable alternative to lifelong medical treatment or the risks of a major abdominal operation.
As surgeons and others skilled in the relevant art will readily appreciate, the above-described known surgical procedures are complex, and even when done very carefully will involve the risk of perforation, bleeding, infection and the like if the incisions are made too deep. It is therefore clearly desirable to develop alternative apparatus and methods for performing laparoscopic vagotomy with very precise incisions to predetermined depth into tissues. Additionally, it is highly desirable to perform the incisions in such a manner that any bodily fluids that do leak from the incision are immediately coagulated, e.g., by applying heat. However, the application of a high enough temperature to effect division and separation of tissue and/or coagulation as described is likely to generate vapors and gases. These can obscure viewing of the operational site by the laparoscopic camera. Therefore, continuous suction of these fluids (liquids or gases and vapors) from the operative field is also highly desirable. The suction must, however, be very precisely applied and controlled to maintain the needed constant insufflation of the abdominal cavity.
All of these needs are very simply and effectively addressed by the present invention, as described below.